Noah, an 18-month-old infant with trisomy 21, was brought to the emergency department for adenovirus bronchiolitis. He was found to meet criteria for severe malnutrition, and his medical team called Child Protective Services (CPS) with concern for neglect. He remained hospitalized for 1 month while a safe discharge was coordinated by the medical and CPS teams. Through this case, we explore racism as a root cause of discharge delays among children with special health care needs who interact with the child welfare system. Our discussion delves into the origins and consequences of racial disproportionality within the child welfare system. We describe how Black children, including those with special health care needs, are disproportionately involved with the child welfare system and highlight the potential role of the health care system in these inequities. Ultimately, this racial disproportionality in CPS involvement may contribute to a cycle of oppression for Black families, undermining family and child health, well-being, and trust in the health care system. Understanding the role of racism in both the child welfare and health care systems can empower pediatric providers to be agents of change. Noah’s case underscores the potential for pediatric providers to either perpetuate or mitigate racial disparities. We propose actions at the individual, institutional, and structural levels, emphasizing the importance of equitable family-centered care practices and trauma-informed care, establishing protocols for the management of potential abuse or neglect, and advocating for policies that reduce racial disparities in child welfare referral, support families, and prevent abuse and neglect.
The Case
Noah is an 18-month-old Black male child born at 33 weeks with trisomy 21, bronchopulmonary dysplasia, atrial septal defect, and repaired duodenal atresia with a gastrostomy tube for supplemental feeds due to inadequate intake and poor growth. He presented to the emergency department (ED) for cough, congestion, and fever and was found to have adenovirus bronchiolitis.
In the ED, Noah’s weight-for-length was below the first percentile for his age; his weight-for-length was recorded at the 10th percentile 3 months prior. His mother said she was giving Noah fewer G-tube feeds because he was showing more interest in solid food. She explained they were currently living in a family shelter and, with prompting, shared that Child Protective Services (CPS) was previously involved in Noah’s care, but that the case was since closed.
Due to Noah’s poor growth and prior CPS involvement, the ED team was concerned about medical neglect and reported the case to CPS.
Noah was admitted to the hospital and provided supportive care for his viral infection. His G-tube feeds were restarted and adjusted by the nutrition team. After 7 days, he demonstrated adequate weight gain and was medically cleared for discharge. However, he remained in the hospital for an additional month while CPS and the medical team determined and coordinated a safe discharge. Ultimately, he was discharged with his mother back to their family shelter.
Many complex factors contributed to this 1-month delay in Noah’s discharge. Through this Health Equity Rounds article, we explore the impact of racism on reporting to CPS and its subsequent implications for children with special health care needs (CSHCNs) within the child welfare system.
Noah’s case represents an amalgam of several real clinical cases to protect the identity of individual patients and families. We note Noah’s racial identity for necessary context as we examine the impact of racism on child health outcomes. We present this case as a call to action for pediatric hospitalists and all clinicians who care for children.
Racism and Racial Disproportionality in the Child Welfare System
Throughout history and in the present day, children of color, in particular Black children, have been overrepresented in the child welfare system—a phenomenon called racial disproportionality (Figure 1). Of the 3 096 101 children reported to CPS in 2022, 22% were Black1 even though only 14% of US children are Black.2 Racial disproportionality in the child welfare system has been linked to factors both external and internal to the child welfare system that are all influenced by racism acting at structural, institutional, and interpersonal levels.3 In this case, we illustrate the interaction of the health care and child welfare systems at each of these levels and the potential to both perpetuate and mitigate child health and welfare inequities.
Factors External to the Child Welfare System
Due to factors external to the child welfare system, Black children are more likely to live in environments where they are at risk of experiencing maltreatment and neglect. The historical legacies of slavery and Jim Crow–era laws have led to racial discrimination across multiple sectors (eg, health care, education, employment, housing, criminal justice) that persists in the present day, resulting in systematic disinvestment and higher levels of poverty in Black communities.3–6 Both poverty and racism directly and indirectly increase exposure to adverse childhood experiences and conditions that place families at risk for maltreatment or neglect such as parental stress, mental illness, incarceration, or intimate partner violence.3,7–9
Factors Internal to the Child Welfare System
Throughout the 20th century, Black children were systematically barred from government benefit programs targeting child poverty. For example, the Aid to Families with Dependent Children Program established by the Social Security Administration in the 1930s granted states discretion on eligibility; many states denied assistance to Black families. Public scrutiny prompted new legislation to prohibit such exclusions. However, new legislation mandated investigations into allegedly unsafe homes, and these investigations often disproportionately targeted Black families.
Although many explicitly racist child welfare laws have since been overturned, the legacy of these policies remains entrenched in our system of “de facto” discrimination (Figure 2). Racial biases among child welfare providers and those who interface with the system, including mandated reporters, lead to disproportionate reporting, investigation, and subsequent separation of Black families.3 During encounters with the child welfare system, Black families frequently experience “disrespectful treatment, cultural misunderstandings, harsh judgments of different parenting styles, and a lack of culturally appropriate services.”3 These challenging interactions can foster mistrust and decrease families’ willingness to engage with social service programs.10
A timeline of impactful laws and policies that collectively perpetuate racial disproportionality in the child welfare system.
A timeline of impactful laws and policies that collectively perpetuate racial disproportionality in the child welfare system.
Factors External and Internal to the Health Care System
Racism within health care can contribute to racial disproportionality in the child welfare system. Implicit racial bias, specifically anti-Black bias, among health care providers is well documented11 and may contribute to disproportionate reporting of Black children, especially when relying on subjective perceptions of risk, which are inherently prone to bias.12
In one study, physicians were more likely to overlook abusive head trauma and view it as accidental in white as compared with Black children.13 Subsequent studies also demonstrated racial bias in medical decision-making and reporting and that nonwhite children with accidental injuries were more frequently reported for abuse even when adjusting for income.12,14–16 In addition to racial bias, prior CPS involvement can also influence providers’ decision to report. A 2024 multicenter study found that referral to CPS prior to consultation of child abuse pediatricians (CAPs) was significantly higher with a family history of prior CPS involvement even when controlling for other factors.17 As mandated reporters and first-line witnesses to injury, malnutrition, and other diagnoses that are sometimes, but not always, associated with abuse or neglect, providers have the potential to either mitigate or perpetuate disproportionality within the child welfare system through reporting practices.
Racial Disproportionality in Child Welfare Involvement Among CSHCNs
As a CSHCN, Noah represents a population of children at particularly high risk of child welfare involvement. Medical complexity and child welfare involvement interact in multiple ways to perpetuate a cycle of distrust and oppression, particularly for Black families. Black families are more likely to have CSHCNs18–20 and to bear the financial and emotional stress of raising CSHCNs, which comes with a higher risk of voluntarily or involuntarily entering the foster care system.21
The American Academy of Pediatrics defines CSHCNs as children “who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” Due to medical advancements, many children with once-fatal diagnoses, such as extreme prematurity, increasingly survive and live with special health care needs (SHCNs).18,19
In the United States, rates of premature birth are 2 times higher for Black compared with white birthing parents even when controlling education and economic status.22,23 The “weathering hypothesis” proposes that chronic stress from chronic and intergenerational exposure to racial discrimination may have lasting and measurable physiologic impacts (eg, increased inflammation, telomere shortening), resulting in a higher risk for premature birth.7,24 These increased rates of prematurity likely contribute to disproportionate numbers of Black CSHCNs.25
Caring for CSHCNs can be emotionally, physically, and financially taxing. Caregivers must navigate complex health and social service systems to access the medical-, home-, and school-based supports their children need, requiring substantial time and effort and often leading to foregone family income.26–28 Poverty exacerbates the challenges of raising CSHCNs, and these challenges contribute to poverty. Every year, between 20 000 and 40 000 children are placed in foster care due to their SHCNs27,28 both voluntarily, when families recognize financial or caretaking constraints, and involuntarily, including in situations when caregiver limitations secondary to poverty are consistent with neglect.20
Implications for Noah’s Story
As we walk through Noah’s hospitalization, we will explore critical moments in his care and the potential for the medical team to both exacerbate and mitigate disparities.
The Medical Team’s Call to CPS
Noah’s ED team contacted CPS as mandated reporters with concern for medical neglect. Although laws vary by state, mandated reporters are generally expected to promptly report any reasonable suspicion of maltreatment with the goal of ensuring child safety.29 CPS in turn evaluates the case for evidence of abuse or neglect, provides or connects families to necessary supports to maintain child safety, and, in some cases, removes the child from an environment that is deemed to be harmful.
Regardless of outcome, CPS investigations are traumatic for all families. The historical context of family separations during slavery and ongoing violence against Black Americans by government agencies (eg, police brutality, mass incarceration)3,30 exacerbates this trauma for Black families. Perceived alignment with CPS can contribute to distrust of the medical system.
Reconciling our legal role as mandated reporters with the potential harms of reporting to CPS and our own clinical judgment can be challenging. These discretionary clinical decisions are rife with subjectivity and prone to bias.31 In a 2008 prospective study, 10% of injuries seen by pediatricians were categorized as suspicious for child abuse, yet only 6% of those injuries were reported to CPS.32 Physicians cited multiple factors influencing their decision to report, including clinical severity, prior CPS involvement, parental support, and the physician’s relationship with the family; a long-standing, positive history with a family decreased likelihood of reporting.32,33
Providers’ concern for abuse or neglect may be heightened for CSHCNs. Intensively managing a child’s medical conditions can be a full-time job and can be made more challenging by financial strain, low parental health literacy, or poor parental physical and mental health.34,35 As providers, we risk overlooking the tremendous challenges inherent to raising a medically complex child and perceiving parents who do not or cannot meet our expectations as neglectful.
Noah’s weight loss concerned ED providers enough to involve CPS, but we cannot overlook how his previous interactions with CPS and family poverty or his racial background impacted that decision. It is plausible that his hospital admission, in which he gained weight and his mother received teaching, education, and a structured feeding plan, could have been a medically sound and responsible alternative to involving CPS. In this instance, the emotional toll, lost wages, and distrust experienced by Noah’s mother during his hospitalization might have been prevented.
Communicating With CPS During and After a Report
In Noah’s case, frequent but fragmented discussions between his CPS caseworker, mother, and medical team resulted in undue scrutiny and investigation of Noah’s mother’s parental fitness. Various clinical team members, including trainees, communicated with Noah’s mother daily but often were not current on his discharge plan. This led Noah’s mother to feel frustrated and fearful and to express anger in conversation. When providers spoke with CPS, they casually mentioned “outbursts” from the parent, interpreted by CPS as oppositional behavior. Furthermore, CPS often asked providers (no matter their role or training) to assess maternal fitness based on behavior and presence at bedside, compliance with hospital policies, alignment with medical treatment, and engagement in care. Providers may not have appreciated the weight of their words and influence on CPS decision-making. Based on these conversations, CPS perceived the need for an urgent investigation into Noah’s safety.
Ensuring child safety is CPS’s mandate—the challenge of this job should not be underestimated, and CPS investigations can be necessary. In Noah’s case, communication with untrained providers resulted in a loss of vital information and nuance, arguably leading to later-debunked conclusions about maternal fitness. The etiology of this communication breakdown is multifaceted, including scheduling/staffing challenges, limited knowledge of the others’ expertise, and difficulties with adequate information sharing. Although the Health Insurance Portability and Accountability Act and state laws generally permit information sharing between the clinician and CPS, the clinical team often does not have the same information as CPS.36–38 A lack of standardized protocols and inadequate training for health care providers on trauma-informed care39 and effective collaboration and communication with CPS exacerbate these challenges (Figure 3).
Determining Safe Discharge Plans for CSHCNs With CPS Involvement
Noah’s case highlights challenges related to discharge when CPS is involved, especially for CSHCNs.
Children with welfare involvement experience discharge delays after medical clearance due to a multitude of factors, including navigating legal processes, finding foster homes, and intensive training of biological or foster families to ensure a safe transition to home after hospitalization.25,40,41 To discharge Noah, CPS first needed to establish that he would be safe with his mother; only then could the medical team determine and coordinate a safe care plan for home.
CSHCNs can also experience discharge delays due to difficulty acquiring home medications, supplies, and equipment and coordinating home services.40 Noah’s discharge required procuring new G-tube supplies, formula, and storage for both his shelter and daycare and coordinating multiple follow-up appointments. Many CSHCNs require even more intensive discharge preparation, such as the coordination of long-term support services (LTSSs) (eg, in-home nursing and therapies). One multicenter study indicated that the need for 8 hours of home nursing correlated with an average of 52 days of delayed hospital discharge.42 Although Medicaid often covers these services for CSHCNs, there is considerable state-level variability, and coverage alone does not ensure availability. For example, LTSS agencies often struggle to staff home nurses for CSHCNs who live in low-income neighborhoods. When these services must be approved and/or coordinated through CPS and/or foster care agencies, the delays can be amplified.
A Call to Action for the Pediatric Hospitalist
Noah’s case demonstrates the external and internal drivers of racial disproportionality in the child welfare system and the role that the health care system can play, particularly for CSHCNs. We offer a call to action at individual, institutional, and structural levels.
Individual Action Steps
At the individual level, we advocate for ongoing personal education on the topics of child abuse and neglect, implicit bias, structural racism, and trauma-informed care (Figure 4). When caring for families, especially those with CSHCNs, hospitalists should establish transparent caregiver expectations with an equity lens, making every effort to “meet families where they are.” For example, hospitalists can call parents who are unable to be at the bedside during rounds, consider resource constraints when formulating discharge plans, and directly provide or connect families to material resources targeting social needs like food insecurity and difficulty with transportation.43 Hospitalists should consider whether it is necessary to ask families about prior CPS involvement, which may bias provider views. In most cases, this information will not be relevant to a patient’s care.
When considering maltreatment, we encourage reflection. Providers may ask themselves, “What is the objective evidence of maltreatment?” or “If this family does not look like me, [or] share my values… how might that affect my thinking?”44 Providers should also remember that they are not alone. Before reporting, consider consulting with colleagues and, when possible, CAPs or teams with expertise evaluating, diagnosing, and treating children with suspected maltreatment.32,33,45–47 Although many hospitals do not have CAPs,47 providers may educate themselves through state-sanctioned mandated reporter trainings and seek support from child abuse pathways and standardized reporting protocols to minimize personal bias.48–54 When reporting a case to CPS, hospitalists should focus on clear and equitable communication. All relevant information should be shared, without deliberate or accidental omissions. Consistency is key; ideally, a single point person should communicate with CPS to maintain continuity of communication and to cultivate trust among family, medical, and CPS teams.45
Finally, providers should be transparent and direct with families about reports, understanding that families may react strongly to this information.
Institutional Action Steps
Institutions can employ standardized care pathways to mitigate bias in CPS reporting. Institutional initiatives have included universal child abuse screenings,49 standardized child abuse evaluation protocols embedded into the electronic medical record,50 and clinical decision tools that identify high-risk children49 and those with abusive head trauma15 Standardized reporting systems can ensure reliability of documentation and facilitate quality improvement.47,51–53 Furthermore, hospitals should critically examine their child welfare reporting practices with a health equity lens, using a quality improvement approach to systematically evaluate inequities and develop strategies to mitigate bias.44,45
Although the number of CAPs in the United States is declining, health systems may be able to access child abuse specialists via e-consults or telehealth.55 Furthermore, institutions can bolster competence and confidence of their staff through training in trauma-informed care, structural determinants of health, harm-reduction strategies, and racial disproportionality in the child welfare system.56
Structural Action Steps
Pediatricians have a powerful voice to advocate for structural change, including for policies related to child abuse prevention and the promotion of equity within the child welfare system. To prevent child abuse, we endorse antipoverty legislation, including paid family medical leave, income support programs like the Earned Income Tax Credit and Child Tax Credit, and policies that increase access to other government benefit programs, such as expanded access to Medicaid and/or Medicaid for all children. These policies can directly influence caregivers’ financial and emotional capacity to provide adequate support and a safe environment for their children.9 For CSHCNs, prevention of child abuse may also include expanded access to high-quality, equitable support services such as home health care services, educational services, and early intervention.57,58 Community support networks, such as family hotlines, may also offer valuable guidance and support to families of CSHCNs. Pediatricians should also consider supporting policies and organizations that aim to bring equity to the child welfare system, such as the upEND Movement59 and JMACForFamilies.60
Conclusion
Noah’s case provides a window into the ways in which health care and child welfare intersect and disproportionately impact children of color, especially those with SHCNs. Although these cases are often nuanced and complex, as pediatric hospitalists, we can contribute to and advocate for improvements to these systems. We can educate ourselves and our colleagues, recognize our own biases, change our behavior, and ensure that we help families access the necessary resources and support they need. As members of health care institutions, we can insist on evidence-based systems that protect against bias and improve outcomes for all children. Although the root causes of racial disproportionality in the child welfare system are complex and structural, there are levers within our control. As hospitalists and pediatric providers, we have a key role to play.
Dr Simard conceptualized the topic, performed literature review, drafted the initial manuscript, reviewed and revised the manuscript, created and revised figures, and approved the final manuscript as submitted. Dr Gerstenzang conceptualized the topic, critically reviewed and revised the manuscript, created and revised figures, and approved the final manuscript as submitted. Ms Gerstenzang provided content expertise that informed concept development, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. Dr Lakhaney, Dr Brown, and Ms. Cardenas provided content expertise, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. Dr Vasan conceptualized the topic, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. Dr Nash conceptualized the topic, critically reviewed and revised the manuscript, critically reviewed and revised figures, supervised the project, and approved the final manuscript as submitted.
CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest relevant to this article to disclose.
FUNDING: Dr Vasan’s effort contributing to this manuscript was funded by the Agency for Healthcare Research and Quality (grant K08HS029396). Dr Nash’s effort contributing to this manuscript was funded by the National Center for Advancing Translational Sciences (grant KL2TR001874).The funders had no role in the conceptualization or preparation of this manuscript.
Acknowledgments
We wish to acknowledge the patients and families whose stories inspired this project. We cannot walk in your shoes but recognize that the medical system played a role in your suffering. We hope by sharing your stories with a goal of educating ourselves and our colleagues, we honor your stories and experiences. We also wish to acknowledge the providers at Morgan Stanley Children’s Hospital and Children’s Hospital of Philadelphia who diligently cared for the patients who inspired this case. Finally, we wish to acknowledge the Health Equity Rounds team based at Boston Medical Center and the Boston Combined Residency Program as well as the Columbia Pediatrics Health Equity Rounds Team, namely Drs Thomas Kuriakose and Elorm Avakame, for their continued leadership in pursuit of health justice.
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